Managment of obesity
- 2. Outline: Definition Screening tools and indications Management steps Approach to patient with obesity Case
- 4. Oman
- 5. Why to stand against obesity ? NICE: Obesity: identification, assessment and management Clinical guideline (2014). The greater the waist circumference and BMI, the greater the risk of CVD, type 2 diabetes, and all-cause mortality. AHA/ACC/TOS 2013
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- 7. Screening ? (BMI) Waist circumference ( mainly if BMI < 35 ) Combined Approach. Note: BMI is not accurate for muscular pt. There are different guidelines for the timing of screening .
- 8. When to screen ? different guidelines Nice 2014: Use Your Clinic Judgment USPSTF Screen all ≥ 18 yrs for obesity. AHA/TOS 2013: BMI at annual visits or more frequently. ( level E )
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- 10. Managment
- 11. Patient centered Plan: State His weight loss goals Addressing barriers to change Developing strategies to maintain long-term lifestyle changes.
- 12. Management : Behavioral Interventions Improving nutrition Increasing physical activity Maintenance !!
- 13. Management: Behavioral interventions and Diet should be initiated in patients who are obese. Then initiate the exercise plan . You may think about the Medications and the surgical interventions later on .
- 14. Behavioral Interventions : The USPSTF recommends : Motivational interviewing 1-2 sessions /months .
- 15. Behavioural interventions Self-monitoring of behaviour and progress Stimulus control Goal setting Slowing rate of eating Ensuring social support Problem solving Skills modifying thoughts Reinforcement of changes Relapse prevention Skills Strategies for dealing with weight regain.
- 18. Dietary Approaches : Which Dietary Approaches Have Been Shown to Be Most Effective for Weight Loss? Adherence to calorie reduction . Simple and realistic diet modifications have the highest likelihood of success AAFP Recommendation :A deficit of at least 500 kcal per day from the total daily calorie requirement can be achieved with intake of 1,200 to 1,500 kcal for women and 1,500 to 1,800 kcal for men.
- 19. Diet Aim: Total energy intake ˂ energy expenditure 2013 AHA/ACC/TOS
- 22. Physical activity The USPSTF recommends : 150 to 300 min/week of moderate-intensity activity or 75 to 150 min/week of vigorous activity per week. Continue even if no weight loss!! Decrease inactivity.
- 23. To prevent obesity: 45–60 min/day of moderate- intensity activity particularly if they do not reduce their energy intake. Obese who lost weight: 60–90 min/day of activity to avoid regaining weight.
- 25. Activity as part of daily life Brisk walking Gardening Cycling Swimming Stair climbing
- 26. Pharmacotherapeutic options Only for patients who have not achieved weight loss goals with diet and lifestyle changes. Extensive discussion of the risks and benefits with the patient .
- 28. Surgical Intervention Bariatric surgery
- 29. AAFP :Bariatric surgery Indications: After Failure of non surgical intervention BMI > = 40 BMI 35 – 40 with co-mobidites (e.g. DM, HTN) Adjustable gastric banding can be consider in also in case of: BMI: 30 – 34.9 with recent onset DM – II. BMI: 30 – 34.9 with obesity-related comorbidities.
- 30. Case
- 31. Case A 52-year-old woman Backgound: Obesity wt 121 kg DM-II for last 9 years Depression HTN DLS OA
- 32. PC: Fatigue, difficulty losing weight, and no motivation. Decrease in her energy level She denies polyuria, polydipsia, polyphagia, blurred vision, or vaginal infections.
- 33. Weight gain started 6 years back. After started on insulin. Pervious trials: Tries to cut down on her eating Hypoglycemia. Fearful of hypoglycemia that she often eats extra snacks.
- 34. Advised in her DM visit to: High BMI Advised: Weight loss and exercise Pain in her knees and ankles makes it difficult to do any exercise.
- 35. She is on: Insulin N: 45 - 35 U Insulin R: 10 U - 20 U. HbA1C: 8.9%
- 36. In the case 1. Multiple Co-morbdites 2. Diet > Hypoglycemia > taking more snakes 3. Arthritis > not able exercise
- 38. Points to Remember Use your clinical judgment to investigate co- morbidities. Manage Comorbidities. Assess readiness: if not ready > give information about obesity and f/u.
- 39. Adult Any underlying causes Eating behaviors Comorbidities (e.g.: DM-II, HTN, CVD , OA, DLS and sleep apnea) Lipid profile, BP and HbA1c.
- 42. Back to our patient Agreed to follow a restricted-calorie diet and to decrease her insulin to 30 U of NPH and 10 U of regular insulin twice daily. As she had no contraindications to metformin (Glucophage), she was also started on 500 mg orally twice daily.
- 43. She returned to clinic 3 months later, still on the same dose of insulin. She was feeling a little less depressed. She continued to complain of fear of hypoglycemia in the middle of the night and was overeating at night. Despite this she had lost 3 kg. Her blood glucose values were still elevated in a range of 7-13 mmol before meals.
- 44. She was reassured that further insulin reduction would prevent hypoglycemia. Her insulin dosage was decreased to 25 U of NPH and 5 U of regular insulin twice daily and metformin was increased to 500 mg three times daily. Two months later, she returned to the clinic with an average blood glucose level of 8.6 mmol. Her weight was now 111 kg, and her HbA1c was 7.5%. She was feeling much more energetic, no longer felt depressed, and was able to start a walking program.
- 45. Important Points : Those who loss their weight quickly are using usually the diet that they can not continue with it for long time , so they remained weight quickly . Reduce the weight over period of months . The main issue not to decrease the weight but how to maintain the weight after reduction. Orlistat ??? Still not available Insluin Victoza for Metabolic syndrome x
- 46. References : NICE: Obesity: identification, assessment and management Clinical guideline (2014). Obesity prevention (2006) AAFP: Update on office based strategies for the management of obesity. Diagnosis and management of obesity guideline 2013 2013 AHA/ACC/TOS: ( American College of Cardiology/American Heart Association, Task Force on Practice Guidelines and The Obesity Society ) Guideline for the Management of Overweight and Obesity in Adults .